Weiser Care Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Weiser, Idaho.
- Location
- 331 East Park Street, Weiser, Idaho 83672
- CMS Provider Number
- 135010
- Inspections on file
- 17
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Weiser Care Of Cascadia during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow the facility’s hand hygiene and infection control policies during housekeeping, medication administration, and laundry operations. A maintenance staff member cleaned one room, removed gloves, then donned new gloves to clean another room without performing hand hygiene in between. Laundry staff handled soiled linens on the dirty side of the laundry room without PPE and then moved to the clean side to fold laundered items, which leadership acknowledged posed a high risk for cross-contamination. An LPN repeatedly prepared and administered medications to multiple residents without performing hand hygiene before medication preparation or before entering and after exiting resident rooms, despite handling items such as cart keys, doorknobs, pitchers, and nutritional supplements. These failures affected all residents receiving medications and laundry services and created the potential for cross-contamination.
The facility failed to maintain a clean, sanitary, and homelike environment when housekeeping and laundry services were not provided as expected for two residents sharing a room. Facility policies required a safe, clean, and comfortable environment and daily room cleaning, including emptying trash and floor care. However, surveyors observed overfilled trash cans, a dirty paper product on the floor, a broken drawer with its outer section stuffed into the opening, and a pillowcase visibly soiled with brown residue on one resident’s bed. Both residents, one with diabetes, epilepsy, and muscle weakness and the other with dementia, legal blindness, PTSD, and Bell’s palsy, reported they were unsure when housekeeping last cleaned their room, and one was unsure when linens were last changed. The Maintenance Director confirmed the room had not been cleaned despite the expectation for daily housekeeping.
A resident with bipolar disorder, obstructive sleep apnea, and personal care needs, identified as an independent smoker, was educated on the facility’s smoking policy and informed that noncompliance would result in a 30-day written discharge notice. After the resident smoked on facility grounds, staff documented that a 30-day notice was issued, but there was no evidence that this notice was provided in writing as required by facility policy and regulation. The resident then requested to leave AMA, and while the record contained a discharge assessment and an AMA risk acknowledgment, it lacked documentation of the required written 30-day discharge notice, which the Administrator and Resource Nurse later confirmed they could not produce.
A deficiency was cited when a resident with dementia and PTSD had a positive PASRR Level I that required referral for a PASRR Level II evaluation, but the facility did not submit or obtain the Level II or provide it to the state agency upon request. Facility policy required that a positive Level I trigger a Level II evaluation and that its recommendations be incorporated into the person-centered care plan. The Medical Records Manager, responsible for PASRRs, reported she had been instructed to submit a Level II only when psychiatric medications were listed and acknowledged that the resident’s Level I should have been forwarded for Level II review.
A resident with a history of stimulant use, depression, and nutritional deficiency had a care plan directing staff to monitor and document specific withdrawal symptoms, including respiratory distress, cardiac decompensation, nausea/vomiting, anxiety, hostility, bloodshot eyes, pinpoint pupils, and diaphoresis. Review of the medical record showed no documentation that staff performed or recorded this required monitoring, and a Resource Nurse confirmed the absence of withdrawal monitoring in the record, demonstrating a failure to implement the comprehensive person-centered care plan as written.
A resident with asthma had a physician’s order for Symbicort inhaler twice daily with instructions to rinse and spit after use, consistent with the drug’s prescribing information to reduce the risk of oral Candida infection. During a medication pass, an LPN handed the inhaler to the resident, who took two puffs and declined water afterward. The LPN did not provide education about the need to rinse the mouth after inhalation and left the resident without reinforcing this instruction, later acknowledging that education should have been provided; the Resource Nurse and DON agreed the resident should have been educated to rinse after using the inhaler.
The facility failed to safely manage smoking paraphernalia and maintain accurate smoking assessments for two residents who smoked off-campus. One resident with multiple chronic conditions, including kidney disease, diabetes, COPD, CHF, and asthma, had conflicting documentation between her care plan and smoking assessment regarding whether she was an independent or dependent smoker, while her assessment also allowed her to keep smoking accessories locked in her room despite the facility’s smoke‑free policy. Another resident with a history of stimulant use, depression, and nutritional deficiency, who had acknowledged the smoke‑free policy and was care planned as an independent smoker, was observed asleep in bed holding a vape device. The DON later stated she was unaware this resident was using a vape and confirmed the expectation that all smoking paraphernalia be stored safely.
A deficiency occurred when a physician did not document a response to a pharmacist’s recommendation following a monthly drug regimen review for a resident receiving budesonide (Symbicort) for COPD. The facility’s policy required providers to document acceptance or rejection of pharmacist recommendations in the medical record. The pharmacist advised adding a “rinse mouth and spit after use” instruction to the steroid inhaler order, consistent with the drug’s prescribing information regarding risk of oral Candida infections, but the order was never updated and no physician response was recorded. The DON reported that nurses were trained to advise mouth rinsing as a standard of practice, yet the lack of an updated order and documented provider response remained for this resident.
A resident with COPD and incomplete quadriplegia was maintained on a daily nicotine transdermal patch and had a PRN order for nicotine gum while also continuing to smoke cigarettes. The MAR showed the patch was administered, and the DON reported the resident was an infrequent smoker but could not provide documentation of infrequent smoking during the period when nicotine replacement therapy was in place. Surveyors found this combination of active nicotine replacement orders and ongoing smoking did not ensure the resident’s drug regimen was free from unnecessary medications and placed the resident at risk for adverse outcomes from overmedication.
A cognitively intact resident with a history of MI and diabetes was found with a seven-day pill container containing tablets on the bedside table, contrary to facility policy requiring medications to be stored in locked compartments. When questioned, the resident reported not knowing what medications were in the container and stated that staff administered his medications. An LPN and the DON later acknowledged that such a pill container with medications should not have been kept in the resident’s room, leading surveyors to cite a deficiency for improper medication storage.
The facility did not ensure that two residents had arbitration agreements specifying a mutually convenient venue for hearings. Instead, their agreements required arbitration to be held in the county where the facility is located before three arbitrators from the American Arbitration Association, without reference to mutual agreement or convenience. During review, the Admission Coordinator acknowledged that these residents should have been asked to sign the updated version of the agreement that includes a mutually agreed upon, convenient venue.
A resident with multiple diagnoses, including muscle weakness and lower back pain, had a urine specimen collected for suspected UTI, with the lab indicating a culture and sensitivity (C&S) would be completed. Before C&S results were available, staff informed the provider that the urine was positive for bacteria, and the provider ordered a 7-day course of IM Rocephin. The C&S was later cancelled due to no sample to perform the test. This sequence of events did not follow the facility’s Antibiotic Stewardship Policy, which required use of McGeer’s Criteria and review of culture and sensitivity reports to guide appropriate antibiotic therapy.
The facility did not have an RN on duty for 8 consecutive hours on two days, as required. The CNO worked from home and was unaware that the hours needed to be consecutive, leading to potential unmet nursing needs for all residents.
The facility did not post nurse staffing information daily or retain it for 18 months as required by policy. The Daily Posted Staffing sheet was outdated, and the Administrator admitted the medical records person missed posting weekend hours. The facility also failed to keep staffing records for the required duration.
The facility failed to properly store and label food, as observed with an undated open soy sauce container, violating the Idaho Food Code and facility policy. Additionally, refrigerator temperatures were not checked for three days, risking contamination and food spoilage for 25 residents.
The facility did not ensure a safe, clean, and homelike environment for two residents, leading to potential safety risks. A resident with dementia, diabetes, and osteoarthritis had a room with damaged walls, while another resident with a shoulder infection and diabetes had a room with a missing baseboard, posing a risk of skin tears. Staff acknowledged these issues should have been addressed.
A facility failed to complete a comprehensive MDS assessment for a resident who developed a stage 3 pressure ulcer. Despite the significant change in condition, the quarterly MDS did not document the ulcer, and a significant change MDS was not completed within the required timeframe. This oversight was confirmed by the Regional Clinical Nurse.
A facility failed to follow its wound care policy for a resident with wounds, risking infection and skin breakdown. The policy requires regular documentation and dressing changes, but bandages dated over ten days old were observed. An RN confirmed that bandages should be changed every three days, indicating a lapse in care for the resident with multiple diagnoses, including a shoulder infection and diabetes.
A facility failed to ensure NAs had the necessary competencies, as observed when an NA improperly used peri-care wipes during catheter care, contrary to guidelines. Additionally, a resident's privacy was compromised when CNAs left window blinds open during a transfer and catheter care, exposing the resident to the outside.
The facility failed to ensure medications were properly dated and not expired. During a medication cart audit, expired Bisacodyl suppositories and undated insulin pens were found. An RN acknowledged the expired medication should have been removed, and another RN confirmed the insulin pens should have been dated when opened.
The facility failed to maintain proper infection control practices, as observed in several instances. An Activities Assistant did not wash hands after removing gloves before serving a resident, and a Lead Cook handled clean dishes without changing gloves after wiping dirty counters. Additionally, two residents were not offered hand hygiene before meals. These lapses were acknowledged by staff, highlighting a breach in infection control protocols.
A resident with Myasthenia Gravis and a pelvis fracture, who uses a wheelchair, was unable to reach the sink faucet, soap, and paper towel dispenser in her room. The facility's administrator was unaware of this accessibility issue, which led to a deficiency in providing a functional environment for the resident.
Failure to Follow Hand Hygiene and Laundry Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to follow its own hand hygiene and infection control policies during housekeeping, medication administration, and laundry operations. The facility’s Hand Hygiene policy, revised 9/15/25, required staff to perform hand hygiene at critical moments, including immediately before and after touching a resident, after contact with objects and surfaces in the resident’s environment, and immediately after PPE removal. During observation on 02/17/26, the Maintenance Director cleaned a resident room by wiping surfaces, sweeping, cleaning the toilet, using an aerosol bottle, and mopping while wearing gloves. After completing these tasks, he removed his gloves, moved to the next room, applied new gloves, and began cleaning without performing hand hygiene between glove removal and donning new gloves. He later stated he normally performs hand hygiene before applying clean gloves and acknowledged he did not do so in this instance, which did not comply with the facility’s policy. Additional deficiencies were identified in the laundry room and during medication administration. During a laundry room inspection on 02/20/26, the Maintenance Director explained that dirty laundry is sorted on the dirty side, washed, then moved to the clean side for drying and folding, and confirmed that laundry staff do not use PPE while sorting dirty laundry. The Maintenance Director and the Administrator both acknowledged there is a high risk for cross-contamination when staff handle dirty laundry without PPE and then move to the clean side to fold clean clothing. On 02/18/26, an LPN was observed repeatedly preparing and administering medications to multiple residents without performing hand hygiene before preparing medications, before entering resident rooms, or after exiting resident rooms, despite touching items such as a medication cart key, a medication room doorknob, a pitcher, and nutritional supplement containers. The LPN later stated that hand hygiene should be performed before and after exiting resident rooms and before preparing medications, and the Infection Preventionist similarly stated that hand hygiene should be performed before entering and after exiting resident rooms and before preparing medications. These observations showed that the facility failed to ensure infection control practices were followed for hand hygiene and PPE use, affecting all residents receiving medications and laundry services and creating the potential for adverse outcomes related to cross-contamination.
Failure to Maintain Clean and Homelike Environment in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, comfortable, sanitary, and homelike environment, as required by its Homelike Environment and Housekeeping & Laundry Services policies. These policies state that residents have the right to a safe, clean, comfortable, and homelike environment that promotes dignity, independence, and quality of life, and that the facility must maintain a sanitary, orderly, and comfortable interior environment at all times. The daily cleaning task list requires staff to empty trash cans, dust, check the floor, and wet mop the floor in each resident room. During observation of the shared room of Resident #5 and Resident #7, surveyors noted two trash cans overfilled with garbage, a dirty paper towel or toilet tissue on the floor in front of the closet, a broken drawer with the outer section stuffed into the drawer area, and a visibly soiled pillowcase with brown residue on Resident #7’s bed. Resident #5, who had diagnoses including diabetes, epilepsy, and muscle weakness, and Resident #7, who had dementia, legal blindness, PTSD, and Bell’s palsy, both stated they were unsure when housekeeping had last cleaned their room, and Resident #7 was unsure when staff had last cleaned his bed linens. The Maintenance Director later stated that the expectation was for housekeeping staff to clean resident rooms daily and acknowledged that this room had not been cleaned as expected.
Failure to Provide Required 30-Day Written Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to provide a required 30-day written notice of discharge to a resident prior to discharge. The facility’s “Notice of Discharge and/or Transfer” policy, dated 10/7/25, stated that systems are implemented to provide written notification to residents prior to transfer. Resident #58 was admitted with multiple diagnoses including bipolar disorder, obstructive sleep apnea, and a need for assistance with personal care. The resident’s care plan, dated 10/23/25, documented that he was an independent smoker who had been educated on the facility’s smoking policy. On 10/29/25 at 10:53 AM, a progress note documented that the resident was educated on appropriate smoking areas and informed that noncompliance would result in issuance of a 30-day written notice as required by policy and regulation. A subsequent progress note on 10/29/25 at 5:10 PM documented that the resident was issued a 30-day notice due to smoking on facility grounds, but the note did not indicate that a written notice was provided. Another progress note at 5:40 PM the same day documented that the resident requested to leave the facility against medical advice. The record contained a discharge assessment (unsigned by the resident) and an acknowledgment of risk for leaving AMA signed by the resident, but there was no documentation of a written 30-day discharge notice. On 2/20/26 at 11:01 AM, the Administrator and Resource Nurse confirmed they were unable to provide documentation that a written 30-day discharge notice had been given to the resident.
Failure to Submit Required PASRR Level II Evaluation
Penalty
Summary
Surveyors found that the facility failed to provide a PASRR Level II to the designated state agency for one resident whose record was reviewed for PASRR documentation. The facility’s PASRR Process policy, revised 8/29/25, stated that a positive PASRR Level I requires an in-depth evaluation by the state-designated authority (PASRR Level II) and that recommendations from the Level II determination must be incorporated into the person-centered care plan. Resident #7 was admitted with multiple diagnoses, including dementia and PTSD. A PASRR Level I dated 8/13/25 documented these diagnoses and referred the resident for further evaluation through a PASRR Level II, but when surveyors requested a copy of the PASRR Level II on 2/19/26, the facility was unable to provide it. The Medical Records Manager, who stated she was responsible for completing residents’ PASRRs, reported she had been instructed to submit a PASRR Level II only if psychiatric medications were listed and confirmed that Resident #7’s PASRR Level I should have been forwarded for a Level II review. This failure to follow the facility’s PASRR policy and to submit the required PASRR Level II for the resident with dementia and PTSD led to the cited deficiency related to coordination of assessments with the pre-admission screening and resident review program and referral for services as needed.
Failure to Implement Care Plan Monitoring for Withdrawal Symptoms
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan for one resident. The facility’s RAI and Comprehensive Care Plans Policy required that care plans be developed and implemented consistent with each resident’s specific condition, risks, and needs. Resident #42, admitted with diagnoses including other stimulant use, depression, and nutritional deficiency, had a care plan revised on 10/13/25 that directed staff to monitor and document for potential signs of withdrawal, including respiratory distress, cardiac decompensation, nausea/vomiting, anxiety, hostility, bloodshot eyes, pinpoint pupils, and diaphoresis. Record review showed no documentation that staff monitored for or recorded any signs or symptoms of withdrawal as required by the care plan, and on 2/20/26 the Resource Nurse confirmed that the resident’s record did not include monitoring for withdrawal symptoms. This failure to carry out the care plan’s specified monitoring for withdrawal constituted noncompliance with the facility’s policy and the requirement to implement a comprehensive care plan according to the resident’s identified needs.
Failure to Educate Resident on Mouth Rinsing After Corticosteroid Inhaler Use
Penalty
Summary
The facility failed to ensure a medication was administered according to professional standards of practice for one resident receiving a corticosteroid inhaler. The Symbicort prescribing information and the physician’s order both specified that the resident should rinse her mouth with water and spit after inhalation to reduce the risk of localized Candida albicans infection in the mouth and throat. Resident #29, who had a diagnosis of asthma and an order for Symbicort two puffs orally twice daily with mouth rinsing afterward, was observed taking two puffs from her inhaler and returning it to the LPN. After administering the inhaler, LPN #1 told the resident she would get her some water, but when the resident stated she did not need the water, the LPN left without providing education on the importance of rinsing her mouth after using the inhaler. In a subsequent interview, LPN #1 acknowledged that the resident did not want the water and admitted she should have educated the resident about rinsing her mouth but did not do so. The Resource Nurse and the DON also stated that the resident should have been educated to rinse her mouth after using the inhaler.
Failure to Safely Manage Smoking Paraphernalia and Smoking Assessments
Penalty
Summary
The facility failed to ensure smoking paraphernalia was stored in a safe location and to maintain accurate smoking assessments for residents who smoke off-campus. The facility’s Non-Smoking Campus Policy, revised 9/12/25, stated that smoking, including e‑cigarettes and vaping devices, was not permitted anywhere on the premises and that the facility maintained a smoke‑free environment. Despite this, Resident #6’s care plan dated 1/8/26 documented that she was an independent smoker who could smoke when off the facility’s property as she desired, while nursing progress notes dated 1/15/26 documented she was a dependent/assisted smoker and to review the evaluation. A smoking assessment dated 1/15/26 documented Resident #6 was a dependent smoker who required assistance but could keep her smoking accessories locked in her room. On 2/17/26 at 10:15 AM, the Administrator stated residents who chose to smoke off-campus were assessed for independent or dependent smoking status, and on 2/19/26 at 4:48 PM, the DON stated Resident #6’s 1/15/26 smoking assessment was not accurate as she was an independent smoker. The facility also failed to ensure safe storage of smoking paraphernalia for Resident #42. Resident #42, admitted with diagnoses including other stimulant use, depression, and nutritional deficiency, had a care plan revised 10/15/25 documenting she was an independent smoker and had been educated on the facility’s smoke/nicotine use policy. A Smoke‑Free Acknowledgment in her record documented the facility’s smoke‑free policy and expectations. On 2/18/26 at 10:35 AM, Resident #42 was observed lying on her bed asleep with a vape device in her right hand. On 2/20/26 at 12:10 PM, the DON stated she was not aware that Resident #42 was using a vape and confirmed that although Resident #42 was an independent smoker, the expectation was that all smoking paraphernalia be stored safely.
Failure to Obtain Physician Response to Pharmacist Recommendation for Steroid Inhaler Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician responded to a pharmacist’s documented recommendation following a monthly drug regimen review. The facility’s Pharmacist Consultation Policy, revised 9/16/25, required that irregularities identified by the pharmacist be reported to the provider and that the provider document acceptance or rejection of the recommendations in the medical record. For one resident reviewed for unnecessary medications, Resident #48, the pharmacist completed a Consultation Report on 11/11/25 recommending that the resident rinse and spit after use of budesonide (Symbicort) to align with the medication’s prescribing information, which warns of localized Candida albicans infections of the mouth and throat and advises rinsing the mouth after inhalation. Resident #48 had a physician’s order dated 9/26/25 for budesonide (Symbicort) inhalation twice daily for COPD. The pharmacist’s Consultation Report specifically requested consideration of adding “rinse mouth out and spit after use” to the budesonide order, but there was no documentation that the physician responded to this recommendation, and the resident’s medication order was not updated to include the mouth-rinsing instruction. A handwritten “Standard of Care” notation appeared at the bottom of the Consultation Report, and during an interview, the DON stated that nurses were expected and trained to advise residents to rinse their mouths after using a steroid inhaler, but acknowledged that the physician’s order had not been updated because it was only a pharmacist recommendation. This lack of documented physician response and order update was identified for 1 of 6 residents reviewed for unnecessary medications and created the potential for the resident to develop oral thrush.
Unnecessary Nicotine Therapy While Resident Continued to Smoke
Penalty
Summary
The facility failed to ensure a resident’s medication regimen was free from unnecessary medications when a resident received nicotine replacement therapy while also smoking cigarettes. The resident, who had multiple diagnoses including incomplete quadriplegia and COPD, was admitted with orders for a 14 mg/24 hr nicotine transdermal patch to be applied daily and nicotine polacrilex gum 4 mg to be given every 3 hours as needed for nicotine craving. The electronic health record documented that the resident was assessed for independence with smoking on two occasions, and the MAR showed that the nicotine patch was administered as ordered. The DON stated the resident was an infrequent smoker but acknowledged the facility could not provide documentation that the resident smoked infrequently while still using the nicotine patches and having an active order for nicotine gum. This resulted in the resident simultaneously having and using nicotine patches, having an order for nicotine gum, and continuing to smoke cigarettes, which the surveyors determined did not meet the requirement that each resident’s drug regimen be free from unnecessary drugs and placed the resident at risk for adverse outcomes from overmedication.
Improper Storage of Medications in Resident Room
Penalty
Summary
The facility failed to ensure medications were safely stored in locked compartments in accordance with its Medication Storage & Labeling policy and professional standards. The policy, released on 10/13/25, required that general medications be stored in locked compartments such as cabinets, carts, or a medication room. During a survey, a seven-day pill container containing white and blue tablets was observed on top of the bedside table of Resident #18, who was awake in bed at the time. Resident #18 had been admitted with multiple diagnoses, including myocardial infarction and diabetes, and a comprehensive MDS assessment documented that he was cognitively intact. When initially asked about the pill container, Resident #18 did not respond. Later, when an LPN asked if he knew what medications were inside the pill container, Resident #18 stated he did not know. He also stated he had not taken any of the medications from the pill container because staff were administering his medications. The presence of the pill container with medications in the resident’s room was acknowledged by nursing leadership, who stated that the pill container with medication inside should not be in the resident’s room. The surveyors determined that this constituted a failure to store medications in locked compartments as required, resulting in a deficiency related to medication storage.
Failure to Use Arbitration Agreements With Mutually Convenient Venue
Penalty
Summary
The facility failed to ensure that its Arbitration Agreement provided for a venue that was convenient to both parties, as required for a neutral and fair arbitration process. Record review showed that one resident admitted on an unspecified date signed an Arbitration Agreement on 8/26/25, and another resident admitted on an unspecified date had a representative sign an Arbitration Agreement on 9/19/25. Both agreements stated that any arbitration hearing would be held in the county where the facility is located before a board of three arbitrators selected from the American Arbitration Association (AAA), without reference to mutual agreement or convenience of venue. During an interview on 2/19/26, the Admission Coordinator reviewed these agreements and produced the facility’s updated Arbitration Agreement, which specified that hearings would be held in a mutually agreed upon venue convenient to both parties before three arbitrators selected from the AAA. The Admission Coordinator stated that the two residents should have been asked to sign the new Arbitration Agreement when the facility updated it. This deficiency was identified for 2 of 3 residents whose arbitration agreements were reviewed, indicating that the facility did not obtain updated agreements reflecting the mutually convenient venue requirement for those residents.
Antibiotic Initiated Without Required Culture and Sensitivity Results
Penalty
Summary
The facility failed to follow its Antibiotic Stewardship Policy by initiating antibiotic therapy without culture and sensitivity results to guide treatment for one resident. The policy, revised on 6/16/25, stated the facility would improve antibiotic use through an Antibiotic Stewardship Program, utilize McGeer's Criteria to validate infections, and routinely review culture and sensitivity reports as part of infection surveillance. For urinary tract infections without an indwelling catheter, McGeer's Criteria require at least one clinical sign or symptom and at least one microbiologic criterion, including specific quantitative culture results. The facility's care plan for the resident, dated 12/29/25, directed staff to monitor, document, and report signs and symptoms of urinary tract infection to the provider as needed. The resident was admitted with multiple diagnoses including muscle weakness, lower back pain, and a need for assistance with personal care. A urine specimen was collected on 1/8/26, with the laboratory report indicating that a culture and sensitivity test would be completed. On 1/9/26, a nursing progress note documented that the provider was informed the urine was positive with bacteria and ordered Rocephin 1 gram intramuscularly for 7 days, while the facility was still waiting for the culture and sensitivity results. A subsequent laboratory report dated 1/14/26 documented that the culture and sensitivity was cancelled due to no sample to perform the test. On 2/20/26, the ADON confirmed that the provider ordered antibiotic therapy before culture and sensitivity results were available to determine appropriate therapy.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of staffing records and staff interviews, revealing that on two specific days, 9/7/24 and 9/8/24, the facility did not meet this requirement. On 9/7/24, the Chief Nursing Officer (CNO) was scheduled to work for only 6 hours, and on 9/8/24, another RN was scheduled to work intermittently. Furthermore, the CNO admitted to working from home on both days and was unaware that the 8 hours of RN coverage needed to be consecutive. This oversight created the potential for harm if nursing needs, whether routine or emergency, went unmet, potentially affecting all residents in the facility.
Failure to Post and Retain Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted daily for each shift and retained for review for 18 months, as required by their policy. The policy, dated 11/28/17, mandates the daily posting of the total number and actual hours worked by RNs, LPNs, CNAs, and the resident census, with records to be kept for a minimum of 18 months or as required by state law. On 9/22/24, it was observed that the Daily Posted Staffing sheet was dated 9/20/24, indicating a failure to post the nursing hours for the last two days. The Administrator acknowledged that the medical records person was responsible for posting the weekend nursing hours on Friday but had missed it. Additionally, the Administrator confirmed on 9/25/24 that the facility had not retained the Daily Posted Staffing Sheets for the required 18 months.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to appropriately store and label food, as observed during a survey. Specifically, an open container of soy sauce was found in the food storage area without a date, which is a violation of the Idaho Food Code and the facility's own policy. The Idaho Food Code requires that refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours must be clearly marked with a date to indicate when it should be consumed, sold, or discarded. The facility's policy also mandates that opened food products should be labeled with their contents and use-by dates. During the survey, it was noted that the soy sauce container was not dated, and the lead staff member acknowledged that it should have been. Additionally, the survey revealed that the temperatures of the back hall snack refrigerator had not been checked and documented for three consecutive days. The Culinary Manager confirmed that the nursing staff was responsible for checking and documenting the refrigerator and freezer temperatures but failed to do so. This oversight in monitoring refrigerator temperatures and the lack of proper food labeling and storage practices had the potential to affect 25 of 26 residents who received meals and snacks at the facility, placing them at risk for potential contamination and use of spoiled foods, which could lead to adverse health outcomes, including food-borne illnesses.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents, leading to a potential safety risk and diminished quality of life. Resident #28, who has dementia, diabetes, and osteoarthritis, was found to have a room with scrapes, chipped paint, and holes in the walls. The Administrator and CNO acknowledged that the walls should have been repaired after the previous resident moved out. Resident #199, with a right shoulder infection and diabetes, had a room where the baseboard by the sink was missing, and part of it was sticking out, posing a risk of skin tears. The Maintenance Manager confirmed that the baseboard should have been fixed.
Failure to Complete Significant Change MDS for Pressure Ulcer
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident who experienced a significant change in condition after developing a pressure ulcer. The resident, who was admitted with diagnoses including dementia, diabetes, and osteoarthritis, developed a silver dollar-sized open wound on the right buttock, which progressed to a stage 3 pressure injury. Despite this significant change, the resident's quarterly MDS did not document the presence of a pressure ulcer, and a significant change MDS was not completed within the required 14 days of diagnosing the pressure ulcer. This oversight was confirmed by the Regional Clinical Nurse, who acknowledged that the MDS should have been modified to reflect the resident's condition accurately.
Failure to Follow Wound Care Policy
Penalty
Summary
The facility failed to adhere to its comprehensive person-centered care plan for a resident with wounds, leading to a potential risk of infection and skin breakdown. The facility's policy on the prevention and treatment of pressure ulcers and other skin alterations requires documentation of wound evaluations with each dressing change or at least weekly. This documentation should include details such as the location, size, exudate, pain, wound bed, and surrounding tissue. However, during an observation on 9/22/24, it was noted that the bandages on the resident's legs and left toe were dated 9/11/24, indicating they had not been changed in accordance with the policy. An RN confirmed that skin tear bandaging should be changed every three days, highlighting a lapse in following the care plan for the resident, who was admitted with multiple diagnoses including a right shoulder infection and diabetes.
Deficiency in Nursing Assistant Competency and Resident Privacy
Penalty
Summary
The facility failed to ensure that Nursing Assistants (NAs) performed tasks for which they had the necessary knowledge, skills, and competencies. This deficiency was observed in one of the six NAs at the facility. The facility's policy on indwelling catheters, revised on 4/12/22, emphasized infection control and proper hygiene practices, including cleaning the catheter-urethral interface daily with soap and water. However, during an observation on 9/24/24, NA #2 was seen using peri-care wipes incorrectly by wiping toward, rather than away from, the urinary meatus, contrary to the guidelines outlined in the facility's policy and other authoritative sources like the CDC and AHRQ. Additionally, the facility failed to maintain the privacy and dignity of a resident during care procedures. On the same day, CNA #1 and NA #2 used a Hoyer lift to transfer a resident from a wheelchair to a bed, leaving the window blinds open and exposing the resident's bottom and perineum area to the outside. This lack of privacy continued as they prepared the resident for catheter care, again with the window blinds open, exposing the resident's urinary meatus area. Both CNA #1 and NA #2 acknowledged that they should have closed the window blinds before transferring the resident and performing catheter care.
Medication Management Deficiency
Penalty
Summary
The facility failed to ensure medications available for residents were properly dated and not expired, as observed during a survey. During an audit of the back hall medication cart, a box of Bisacodyl suppositories with an expiration date of November 2023 was found, indicating it should have been removed from the cart. RN #1 acknowledged that the expired medication should have been taken off the cart. Additionally, during the front hall medication cart audit, two insulin pens were found without dates in the top drawer. RN #2 was unsure if the insulin pens had been used and confirmed that they should have been dated when opened. This oversight was reiterated by RN #2, who stated that the insulin pen was not dated as required.
Infection Control Lapses in Hand Hygiene and Kitchen Practices
Penalty
Summary
The facility failed to adhere to infection control and prevention practices, impacting the safety and sanitation of the environment. An Activities Assistant was observed removing gloves without washing hands before serving a resident lemonade, only sanitizing her hands after delivering the drink. In the kitchen, a Lead Cook was seen wiping dirty counters and handling clean dishes without changing gloves or washing hands. Additionally, the Business Office Manager delivered breakfast meals to two residents without offering them hand hygiene before eating. These actions were acknowledged by staff, indicating a lapse in following proper infection control protocols.
Inaccessible Facilities for Wheelchair-Bound Resident
Penalty
Summary
The facility failed to provide a functional environment for a resident, leading to a deficiency in meeting the resident's physical needs. This issue was identified during an observation on September 24, 2024, when a resident who uses a wheelchair was unable to reach the sink faucet and handles, soap, or paper towel dispenser in her room. The resident had been admitted with multiple diagnoses, including Myasthenia Gravis and a left pelvis fracture, which necessitated the use of a wheelchair. The facility's administrator acknowledged the issue, stating he was unaware that these items were inaccessible to residents in wheelchairs.
Latest citations in Idaho
A resident admitted with a diagnosis of PTSD and severe cognitive deficits had an admission MDS and an Interim History and Physical documenting PTSD, but the Idaho PASRR Level I form incorrectly indicated no major mental illness, even though PTSD is listed on the form as a major mental illness. The SSD stated he reviewed hospital records and the chart but missed the PTSD diagnosis and did not mark it on the PASARR, contrary to facility expectations and policy requiring accurate pre-admission screening for serious mental disorders and appropriate follow-up evaluation when a Level I screen is positive.
A resident with COPD and dementia, receiving scheduled nebulizer treatments, was found on multiple occasions to have a nebulizer mask stored on top of the machine rather than in a sanitary manner. A CNA and a nurse aide in training confirmed the mask’s placement, and an LPN reported that masks were routinely cleaned, dried, and then stored on top of the machine. The DON later acknowledged that masks should be washed, dried, and placed on a clean surface, and facility policy required oxygen and respiratory supplies to be stored in a plastic bag when not in use.
Staff failed to consistently implement and follow Enhanced Barrier Precautions (EBP) during wound care for two residents. For a resident with an indwelling urinary catheter and an EBP order, an RN and a CNA removed their gowns after catheter care and performed a heel and toe dressing change wearing only gloves, despite a door sign requiring gown and gloves for wound care and other high-contact care. For another resident with multiple open leg wounds and active wound care orders, an RN and a nurse aide performed dressing changes with gloves only, without gowns, and there was no EBP signage or order in place. Interviews with nursing staff, the IP, and the DON revealed inconsistent understanding and application of the facility’s EBP policy, which requires gown and gloves for high-contact care activities, including wound care and device care, for residents with chronic wounds or indwelling devices.
A resident with diabetes, chronic kidney disease, and a history of breast cancer had previously received PPSV23 and PCV13 at the appropriate age, but review of the EMR and vaccine consent form showed the pneumococcal section was marked as "not needed" and no additional pneumococcal vaccine was offered. The ADON/IP acknowledged that, according to CDC guidelines, the resident was not fully vaccinated and should have been offered PCV20, and the DON stated her expectation that vaccine status be reviewed on admission and tracked to ensure residents are fully vaccinated.
Two residents who experienced emergent hospital transfers for issues including abnormal critical labs, uncontrollable pain, and SOB with low O2 saturation were not provided with required written bed-hold policies and transfer notices. One resident had severely impaired cognition, and another was cognitively intact and later died at the hospital. Progress notes documented the transfers and that contacts or family were notified, but there was no documentation that written notices addressing bed-hold, appeal rights, or ombudsman information were given, despite facility policies requiring such written information at admission and again at or shortly after transfer. The Administrator confirmed that bed-hold notices were not sent for these residents.
Two residents who required staff assistance with ADLs did not receive showers and hair washing as care-planned and expected. One resident with dementia and cervical spine conditions was observed with flaky skin and greasy hair, and the family’s shower calendar showed only four showers in a month despite an expectation of three per week, with no refusals documented in the record or care plan. Another cognitively intact resident with quadriplegia and spinal stenosis reported rarely receiving scheduled showers, and was observed with long, greasy hair, again with no refusals documented. The DON and Administrator acknowledged CNAs believed they could not provide baths without a dedicated bath team and historically had no room assignments, despite facility policy requiring provision and documentation of ADL care and refusals.
Surveyors found multiple expired medications, including various insulin products, Trulicity injection pens, and a large bottle of Gabapentin solution, stored in a medication room refrigerator and still available for use. The MDS coordinator confirmed the drugs were expired. The DON reported that no one had been specifically assigned to check the refrigerator for expired medications, while an LPN stated she only reviewed medication carts and did not check refrigerated stock. Facility policies required checking expiration/beyond-use dates before administration, dating multi-dose containers when opened, discarding them within specified time frames, and returning or destroying outdated medications, but these procedures were not followed for the medications in the refrigerator.
Surveyors found that the facility did not maintain sanitary conditions in the walk-in freezer and ice machine area. Ice buildup on freezer lines was encroaching on a box of burritos, and an ice scoop holder attached to the ice machine contained standing water with two scoops resting in it and no visible drainage. The Dietary Manager acknowledged the recurring ice buildup and reported that the standing water issue had not previously been raised. These practices did not follow the facility’s policies for food safety, storage, and ice machine preventative maintenance and had the potential to affect 46 residents who consumed food from the kitchen.
A resident with dementia, malnutrition, anemia, CKD3, and other comorbidities was care planned as at risk for nutritional decline and dehydration, with weekly weights and RD review ordered. An RD later documented poor PO intake averaging about 31%, fluid intake around 612 ml with meals, and no routine supplements in place, and recommended starting 2 oz Med Pass BID between meals with nursing to document consumption. No Med Pass order was entered into the EMR, and the resident did not receive the supplement, while experiencing a 10‑lb (6.8%) weight loss over several months. Interviews showed the RD typically communicated recommendations via email and NAR meetings, but NAR meetings had not been held consistently and no email or other system ensured the recommendation was received or implemented; requested policies on RD recommendations/supplement orders and weight loss were not provided.
A resident with multiple cardiopulmonary diagnoses received continuous O2 at 1.5 LPM via nasal cannula without a physician order or corresponding MAR documentation, despite the care plan and MDS indicating a need for and receipt of oxygen therapy. Surveyors observed the resident on oxygen on several occasions, initially without humidification and later with humidification. An LPN and the DON both confirmed at the bedside that the resident had been on oxygen since admission without a provider order, and that no monitoring was documented, contrary to facility policy requiring verification of a provider order before initiating or changing oxygen therapy.
Failure to Update PASARR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to ensure that a PASARR Level I screen was accurately completed and updated to reflect a major mental illness diagnosis for one resident. The resident’s admission MDS, with an ARD of 03/30/26, showed a diagnosis of Post-Traumatic Stress Disorder (PTSD) and a BIMS score of 3/15, indicating severe cognitive deficits. An Interim History and Physical dated 03/25/26 also documented PTSD as a diagnosis. However, the Idaho PASRR Level I form dated 03/19/26 indicated “No” under the section asking whether the individual had any major mental illnesses, despite PTSD being listed on the form as a qualifying major mental illness and despite the resident having that diagnosis. The Social Services Director reported that he reviewed hospital records and the resident’s chart to ensure that diagnoses on the admitting PASARR matched the resident’s conditions, and he confirmed the resident was admitted with PTSD. He acknowledged that he missed the PTSD diagnosis and that it should have been marked on the PASARR. During an interview, the DON and Administrator stated the expectation that all PASARRs be correct and that, if not correct at admission, a new PASARR should be submitted. The facility’s PASRR policy specified that potential admissions are to be screened for serious mental disorders or intellectual disabilities prior to admission and that a positive Level I screen requires a Level II evaluation by the state-designated authority prior to admission unless otherwise authorized.
Improper Storage of Nebulizer Mask and Respiratory Supplies
Penalty
Summary
Surveyors identified a deficiency in the sanitary storage of respiratory equipment for one resident receiving respiratory care. The resident was admitted with COPD and unspecified dementia and had care plan focuses for terminal prognosis due to COPD and shortness of breath, with interventions including administration of inhalers and nebulized medications as ordered. Physician orders included scheduled ipratropium-albuterol nebulizer treatments twice daily for COPD. During multiple observations in the resident’s shared room, the nebulizer mask was seen lying on top of the nebulizer machine rather than being stored in a sanitary manner. Staff interviews confirmed the observed storage practice. A CNA and a nurse aide in training each verified that the nebulizer mask was lying on top of the machine at the times of observation. An LPN stated that masks were cleaned after use, dried, and then stored on top of the machine, and acknowledged this could be an infection control issue. During a later observation, the LPN again confirmed the mask was on top of the machine. In an interview, the DON, with the Administrator present, stated the mask should be washed, dried, and placed on a clean surface and acknowledged it could be an infection control issue, and the facility’s written policy specified that oxygen and respiratory supplies were to be stored in a plastic bag when not in use.
Failure to Implement and Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use and implementation of Enhanced Barrier Precautions (EBP) during wound care. One resident with an indwelling urinary catheter had an active order and care plan for EBP, and a door sign specifying that gown and gloves were required for high-contact resident care activities, including wound care and device care. During an observation, an RN and a CNA entered this resident’s room, performed hand hygiene, donned gown and gloves, and completed catheter care in accordance with the posted EBP instructions. However, after completing catheter care, the RN instructed the CNA that they could remove their gowns because EBP was “only for the catheter,” and both staff removed their gowns and gloves, performed hand hygiene, and then donned only clean gloves to perform a dressing change on the resident’s right heel and pinky toe, despite the door sign indicating gown and gloves were required for wound care. A second resident had multiple open wounds on both lower extremities that required cleansing, application of collagen with wound gel and alginate, and coverage with border gauze dressings. Progress notes documented that these wounds originated as skin tears and were slowly healing, and active wound care orders were in place. During an observation of wound care for this resident, an RN and a nurse aide performed hand hygiene and donned gloves but did not wear gowns. There was no EBP sign or PPE set up outside the room, and there was no order for EBP in the electronic medical record, even though the resident had open wounds requiring dressing changes. In interviews, the RN stated that EBP was required for chronic wounds such as pressure, venous, and arterial wounds, and that EBP for the first resident applied only to catheter care. The CNA reported that she relied on the door sign and believed she only needed to gown for catheter care, brief care, or toileting, and not for transferring if she was not in contact with the catheter. The Infection Preventionist explained that EBP was used for chronic wounds and indwelling devices and stated that staff would only need to gown when providing care to the Foley catheter, while the DON stated that EBP was for residents with devices or dressing changes to prevent MDROs and that staff should wear gown and gloves even when not providing direct catheter care. The facility’s written EBP policy specified that EBP applies to residents with chronic wounds and/or indwelling medical devices and that PPE for EBP is necessary when performing high-contact care activities, including wound care and medical device care, which was not consistently followed in the observed wound care encounters.
Failure to Offer Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its pneumococcal vaccination policy for one resident. The resident was admitted with diagnoses including diabetes mellitus, chronic kidney disease, and a history of malignant neoplasm of the breast, and was over the age threshold referenced in CDC guidance. Record review showed the resident had previously received PPSV23 on 06/07/04 and PCV13 (Prevnar 13) on 11/04/14, both administered when the resident was older than the specified age. The resident’s Informed Consent Form for vaccines, dated 09/17/25, had the pneumococcal section marked as “not needed,” despite documentation of prior PPSV23 and PCV13 doses. During interviews, the ADON/Infection Preventionist stated she tracks resident vaccine records on a spreadsheet and confirmed that, based on CDC recommendations, the resident was not fully vaccinated and should have been offered PCV20. She also stated she did not know why “not needed” was written on the consent form. The DON stated her expectation was that residents’ vaccine status would be reviewed on admission, tracked when due, and that the IP nurse would review pneumonia vaccine status to determine if residents were fully vaccinated and offer the vaccine if not. Review of the facility’s pneumococcal vaccination policy and the CDC Adult Immunization Schedule showed that, for adults who previously received both PCV13 and PPSV23 with PPSV23 given at age 65 or older, one dose of PCV20 or PCV21 should be considered at least five years after the last pneumococcal vaccine dose, indicating the resident met criteria to be offered an additional pneumococcal vaccine dose.
Failure to Provide Required Bed-Hold and Transfer Notices for Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold policies and transfer notices to two residents and/or their resident representatives when the residents were emergently transferred to the hospital. One resident had severely impaired cognition with a BIMS score of 3/15 and was transferred to the hospital due to abnormal critical lab results, then later returned to the facility. Documentation showed that the facility called the contact on file and a POA returned the call, but there was no documentation that a written transfer notice or bed-hold information was provided. The facility’s own policy required that written transfer/discharge notices include the reason for transfer, effective date, receiving location, a statement of the right to appeal, and contact information for the state LTC ombudsman and protection and advocacy agencies, as well as sending a copy to the ombudsman. A second resident, who had intact cognition with a BIMS score of 15/15, was transferred to the hospital on one occasion for uncontrollable pain and returned to the facility, and on another occasion for SOB, tremors in both arms, and oxygen saturation below 88%, after which the resident expired at the hospital. Progress notes documented the transfers and that the family was notified, but there was no documentation that written transfer notices or bed-hold policies were provided at either transfer. The facility’s bed-hold policy required that all residents or their representatives, regardless of payor source, receive written information about facility and state bed-hold policies twice: in advance of transfer (e.g., in the admission packet) and again at the time of transfer, or within 24 hours for emergency transfers. During an interview, the Administrator confirmed that bed-hold notices had not been sent for these two residents.
Failure to Provide Required Showering and Hygiene Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide required assistance with showering and personal hygiene for two residents who were dependent on staff for ADLs. One resident was observed with flaky skin and greasy hair, and the resident’s family member reported the resident was supposed to receive three showers or baths per week but was “lucky to get one.” The family maintained a calendar showing the resident received only four showers in the month of April. The resident’s admission record showed diagnoses including traumatic spondylolisthesis of the cervical spine, unspecified dementia, and cervical spinal stenosis. The quarterly MDS documented moderate cognitive impairment with a BIMS score of 10 and a need for substantial/maximal assistance with showering/bathing, with no documentation of care refusals. The resident’s care plan identified an ADL self-care performance deficit related to impaired balance, limited mobility, limited ROM, and neck pain, and contained no documentation of rejection of care or a pattern of negative responses. A second resident was observed with waist-length hair that appeared greasy at the crown and in need of washing. This resident stated she was supposed to receive three showers or baths per week but was “lucky” to get one, and reported staff told her they were short-staffed and that there was no bath team. Her admission record listed diagnoses including quadriplegia at C5–C7, bipolar disorder, and spinal stenosis. Her quarterly MDS documented that she was cognitively intact with a BIMS score of 15 and required partial/moderate assistance for showering/bathing, with no documentation of refusing care. Her care plan identified an ADL self-care performance deficit related to incomplete quadriplegia and did not document any concerns with rejection of care for ADLs, including showering. The DON and Administrator acknowledged that CNAs believed they were short-staffed without a bath team and were unaccustomed to providing baths and grooming when the bath team was unavailable, and that previously there had been no CNA room assignments, resulting in a lack of accountability for residents’ care. The facility’s ADL policy required that residents unable to perform ADLs independently receive services necessary to maintain grooming and personal hygiene and that refusals be documented in the clinical record.
Expired Medications Not Removed From Medication Room Refrigerator
Penalty
Summary
Surveyors identified a failure to properly manage and discard expired medications stored in a medication room refrigerator. During an observation of the medication storage room refrigerator with the Minimum Data Set Coordinator, multiple expired medications were found, including one Lispro insulin vial and one Lantus insulin vial, both with expiration dates of 01/23/26 and no open dates on the vials. An Apidra Solostar insulin pen with an expiration date of 02/04/26, a Trulicity 3 mg/0.5 ml injection pen carton with two pens remaining and an expiration date of 01/16/26 with no open date on the carton, and a 500 ml bottle of Gabapentin solution with 450 ml remaining and an expiration date of 10/02/23 with no open date on the bottle were also present. These medications remained stored in the refrigerator and available for use despite being outdated. During interviews, the MDS Coordinator confirmed that the medications in the storage refrigerator were expired and stated that an LPN was responsible for monitoring medication expiration dates for medications stored there. The DON reported that she did not think anyone had been assigned to check the medication storage refrigerator for expired medications and acknowledged that expired medications should have been destroyed by staff or returned to the pharmacy. The LPN later stated that she reviewed all medication carts for expired medications but did not check the medications stored in the refrigerator. Review of facility policies showed requirements that expiration or beyond-use dates be checked prior to administration, that multi-dose containers be dated when opened and discarded within 28 days unless otherwise specified, and that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, which were not followed in this instance.
Unsanitary Walk-In Freezer and Ice Scoop Storage Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in food storage and ice handling areas. During an initial kitchen tour, the walk-in freezer was found to have ice buildup on the freezer lines that extended far enough to encroach on the upper stacked box of burritos. The Dietary Manager acknowledged during interview that this ice buildup had occurred before. At the end of the tour, inspection of the ice machine revealed an ice scoop holder mounted on the side of the machine containing two ice scoops, with approximately 20 milliliters of standing water in the bottom of the holder and the scoops in direct contact with the water, and no visible way for the water to drain. The Dietary Manager stated that no one had ever mentioned the standing water in the scoop holder before. These conditions were inconsistent with the facility’s written policies on food safety and storage and on ice machine preventative maintenance, which require that food and supplies be stored and handled to ensure safety and sanitation and that exterior surfaces, including the catch basin, be wiped down with a clean cloth and food-safe sanitizer. The deficiency had the potential to affect 46 residents who consumed food from the kitchen.
Failure to Implement RD Supplement Recommendation for Resident With Weight Loss
Penalty
Summary
The facility failed to implement a registered dietician’s (RD) recommendation to address gradual weight loss for one resident. The resident was admitted with dementia with behavioral disturbance, malnutrition, anemia, osteoporosis, B vitamin deficiency, history of alcohol abuse, peripheral vascular disease, hypertension, and stage 3 chronic kidney disease. Her care plan identified her as at risk for nutritional decline and dehydration or potential fluid deficit, with approaches including weekly weights, completion of a Mini Nutritional Assessment, provision of meals per physician diet order with intake documentation, and RD review as indicated. A quarterly MDS showed severely impaired cognition, risk for pressure ulcers, receipt of a therapeutic diet, and a need for set-up or clean-up assistance with eating. On a nutritional review, the RD documented that the resident’s average intake was about 31%, average fluid intake with meals was about 612 ml, and that there were no routine supplements in place, although the RD felt she would benefit from additional support. The RD recommended initiating 2 oz Med Pass BID between meals and directed nursing to document the amount consumed. However, there was no corresponding Med Pass order in the EMR, and the resident did not receive the supplement. The resident experienced a 10‑lb (6.8%) weight loss over four months, with a low of 128.4 lbs. Interviews revealed that the RD expected recommendations to be implemented within 48 hours and typically communicated them via email to nursing and through Nutrition At Risk (NAR) meetings, but there had been no consistent NAR meetings and no email or other system in place to ensure the RD’s recommendation for Med Pass was communicated and implemented. Requested policies on RD recommendations/supplement orders and weight loss were not provided before survey exit.
Oxygen Therapy Administered Without Physician Order or Documentation
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician’s order, in accordance with professional standards of practice and facility policy, before administering oxygen to a resident. The resident was admitted with diagnoses including pulmonary hypertension, malignant neoplasm of the cardia and lower third of the esophagus, abnormal lung findings, and chronic systolic congestive heart failure. The resident’s care plan documented a potential for altered respiratory status and the need for oxygen therapy via nasal cannula, and the admission MDS indicated the resident received oxygen while in the facility. However, review of the electronic medical record, including the Order Recap Report, MAR, and progress notes for the relevant period, revealed no physician order for oxygen and no documentation that oxygen was being administered or monitored. Surveyor observations on multiple dates showed the resident receiving oxygen via nasal cannula at 1.5 LPM, initially without humidification and later with humidification. During interviews at the bedside, an LPN confirmed the resident was receiving oxygen at 1.5 LPM, acknowledged there was no physician’s order for oxygen, and stated the resident had been on oxygen since admission, with no MAR documentation of monitoring. The DON also confirmed the resident was receiving oxygen at 1.5 LPM without a corresponding physician’s order and stated that an order should have been obtained before oxygen was administered. Review of the facility’s “Oxygen Administration, Safety, Storage & Maintenance” policy showed that staff were required to verify a provider order prior to initiating or changing oxygen therapy, which was not followed in this case.
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